The Urban Health Penalty and Jefferson Health System\u27s Community Health Collaboration

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The Association Between Food Insecurity and Physical Activity in Adults with Serious Mental Illness Living in Supportive Housing

Rates of food insecurity are high among adults with serious mental illness (SMI); this population also engages in less physical activity than the general population. However, the relationship between food insecurity and physical activity in this group has not been explored. We examined food insecurity prevalence and its association with physical activity in 314 adults with SMI living in supportive housing in New York City and Philadelphia and enrolled in an institutional review board-approved randomized controlled trial of a Peer Group Lifestyle Balance (PGLB) program. We analyzed 2014 baseline survey data, including demographic data and self-reported food security, and four self-reported physical activity outcomes: any physical activity per week (yes/no) and 2) total, 3) moderate, or 4) vigorous physical activity minutes per week. A logistic regression model examined food se- curity as a predictor of any physical activity; zero-inflated negative binomial regression models were used for the other three physical activity outcomes; demographic and clinical predictors were assessed for inclusion in models. Over half of participants (51.7%) reported low or very low levels of food security. Relationships between food insecurity and three physical activity measures (any physical activity, total weekly minutes, and moderate weekly minutes) were non-significant; those with lower food security were more likely to engage in vigorous physical activity. The high food insecurity prevalence highlights the importance of measuring and addressing food security in populations experiencing SMI; measuring physical activity is also important for tailored lifestyle recommendations. Future studies should examine longitudinal changes in food security and physical activity

\u27It\u27s common sense that an individual must eat\u27: Advocating for food justice with people with psychiatric disabilities through photovoice.

BACKGROUND: People with SMI have often been excluded in advocacy efforts focused on physical health, health care and health and social policy. OBJECTIVE: Following a Photovoice project focused on barriers to healthy eating and physical activity in urban neighbourhoods, participant-researchers were invited to present their insights in community advocacy settings. The purpose of this study was to explore the feasibility and participant-researchers\u27 experience of these community advocacy activities. DESIGN: We held four focus groups with the eight participant-researchers after each community advocacy activity to explore their experience with public speaking, presenting their experiences and advocating. SETTING AND PARTICIPANTS: People with serious mental illness who were overweight/obese living in supportive housing. ANALYSIS APPROACH: Qualitative analysis of the focus group transcripts, using a modified grounded theory approach followed by structured coding focused on empowerment, participation and non-discrimination. RESULTS: Participant-researchers gave three oral presentations of their photographs at a variety of community-based programmes and settings and participated in a rally to advocate for SNAP benefits. Two themes emerged from analysis: (a) Empowerment (the level of choice, influence and control that users of mental health services can exercise over events in their lives) and (b) Barriers to Empowerment (obstacles to participation and well-being). CONCLUSIONS: This evaluation strengthens the evidence that it is feasible for participant-researchers in Photovoice projects to engage in robust advocacy activities, such as presentations and discussions with local policymakers. During focus groups, participant-researchers demonstrated realistic optimism towards their roles as change agents and influencers in spite of acknowledged systemic barriers

Beyond Lifestyle Factors: Exploring The Role of The Social Determinants of Health in Weight Loss Attempts in People with Serious Mental Illness Living in Supportive Housings Settings

Background: People with serious mental illness (SMI) experience marked health disparities from preventable and treatable conditions and a prevalence of overweight/obesity almost twice the general US population. The problems and proposed solutions to obesity-related morbidity in people with SMI have mainly focused on the individual level. Difficulties with healthy eating and physical activity are attributed to behavior or lifestyle factors, such as poor diet, sedentary routines, and low motivation, as well as increasing use of second generation antipsychotic medications. Larger system level factors have received limited attention in the response to this epidemic and past research has not adequately involved people with SMI in a deeper exploration of these issues. Health disparities involving the problem of obesity in people with SMI have not been considered using a human rights framework. Methods: This dissertation used a participatory action orientation with a mixed-methods sequential explanatory model to explore the healthy equity factors that facilitate or limit clinically significant weight loss in people with SMI who are overweight or obese and participating in a 12-month, peer-led, group healthy lifestyle intervention. Study one utilized baseline data of 93 participants in the intervention arm of the parent Peer Group Lifestyle Balance study. Quantitative analysis was used to explore associations between the predictor variable of food security at baseline and the outcome variable of 6-month weight change. Studies two and three were developed through a participatory Photovoice project with 8 participant co-researchers. Study two explored the lived experience of healthy eating and physical activity through 7 weekly sessions with the co-researchers consisting of individual photo-elicitation and group discussion of photos and captions. Study three explored the co-researchers experience of presenting at four varied community events. Results: The results of the quantitative analysis revealed that 76.2% percent of the sample reported some level of food insecurity, 22.6% with marginal food security, 28.6% with low food security, and 25.0% with very low food security. The mean weight change at 6 months was -2.86 pounds (SD = 13.67) with a range of -47.6 to 33.0. At six months, 65% of the total sample had a weight lower than their baseline weight. The association between metformin use and diagnosis of diabetes with weight change was significant with the metformin group losing a mean of 6.7lbs vs 0.3lbs in intervention participants not taking metformin. The analysis of the main effect for baseline food security on weight change between baseline and 6 months approached significance (F (2, 81) = 3.075, p =.052, partial η2 = .071). In the Photovoice project, the eight co-researchers selected a total of 33 photos and captions to represent their experience and organized the photos into five themes: 1) Corner stores in our neighborhood, 2) Challenges to healthy eating and exercise, 3) Healthy eating ideas with limited supplies, 4) Exercise: Challenges and options, and 5) Recovery: Body, mind, and spirit. The themes from the photographs reflected two overarching themes: structural barriers and overcoming structural barriers. Four overlapping themes emerged from the analysis of the post-advocacy presentations: 1) Empowerment, 2) Influence, 3) Barriers to participation, and 4) The system. Conclusion: The strengths of this study are grounded in the mixed-methods exploration of the impact of the social determinants of health on healthy eating and physical activity in a highly marginalized population with significant health disparities resulting in part from obesity-related conditions. The human rights framework provides an organizing lens to understand the findings of this study. The qualitative findings provided concrete explanations of the quantitative findings. The Adult Food Security Survey revealed a 76% rate of any level of food insecurity in the sample. Fifty-four percent of the sample reported low or very low food security, higher than the national average of 12.3% (United States Department of Agriculture, 2015). The main effect of food security on 6-month weight change approached significance. Documenting this rate of food insecurity in the population is a critical finding and suggests many people with SMI are not achieving the right to food, despite living in supportive housing settings and receiving Supplemental Nutrition Assistance Program (SNAP) benefits. The reasons for this inequality are complex and the Photovoice project described in Chapter 3 provides some insights into this situation from the population itself. The high cost of poor quality food available in urban corner stores and fast food establishments as well as the cost of transportation out of the neighborhood contribute directly to food insecurity. The use of food pantries, with variable food quality is a consequence of food insecurity and limited SNAP benefits in the population. These situations are a threat not just to the right to healthy food, but the right to health itself. The easy availability of tobacco and alcohol products through neighborhood convenience stores, the lack of safe places to exercise, and increased rates of violence seriously impede opportunities to live a healthy life. The qualitative findings were also useful in expanding not only our understanding of the problem, but the strengths of the populations, and potential real-world solutions. Multiple level factors are making a positive contribution to the rights of people with psychiatric disabilities. The quantitative analysis showed that 65% of the total sample had lost weight in the first 6 months of participation in the project. Co-researchers in the Photovoice project reported many examples of knowledge and skills they had learned or improved through participation in the PGLB study. These skills, which were taught and modeled by specially trained peer specialists, were used to overcome structural barriers to healthy eating and physical activity, and likely contributed to weight loss. Co-researchers in the advocacy sessions of the project discussed experiences of segregation, stigma, distrust, and indignity arising from a system that does not always respect the rights of people with psychiatric disabilities. Most people with SMI have experienced significant past social traumas that contribute to, or arise from, their experience of psychiatric disability. Nevertheless, the co-researchers in this project displayed and articulated a sense of empowerment and pride in raising awareness of their experiences and being heard by stakeholders, advocates, and peers during their presentations. These experiences provide evidence that multiple groups in public health and local government are interested in and committed to the rights of people with disabilities.Dr.P.H., Community Health and Prevention -- Drexel University, 201

Capacity Building for Participatory Health Services Research in Housing First

Background: Pathways to Housing ends chronic homelessness for individuals with serious mental illness (SMI) by providing housing first, and then combining that housing with supportive treatment services in the area of mental and physical health, substance abuse, education, and employment. Housing is provided in apartments scattered throughout a community. This scattered site model fosters a sense of home and self-determination, and it helps speed client\u27s reintegration into the community. The Pathways model has been remarkable successful in addressing chronic homelessness. Research Question What are the chronic physical disease self management support needs of Pathways to Housing clients

Introduction to Community-Based Participatory Research

Objectives: Understand the core principles of CBPR Discuss one example of a CBPR project using Photovoice Describe the CBPR conceptual model Apply the CBPR conceptual model during a brief group thought projec

Baseline Monitoring of Standard Health Indicators in a Formerly Homeless Population

Research Question: What are the rates of baseline health status indicators recording at Pathways to Housing (PTH) using select recommended measures from the National Association of State Mental Health Program Directors (NASMHPD) and the Healthcare Effectiveness Data Information Set (HEDIS)? How do health indicators compare between clients receiving direct clinical care in the integrated care program vs non-integrated care clients

JFMA Street Outreach: A Resident-Run Street Medicine Program A retrospective chart review examining the needs of a vulnerable population and services provided

In Philadelphia it is estimated that over 12,000 people experience homelessness annually, and up to 500 individuals live on the street on any given day.1 Project HOME coordinates the City of Philadelphia’s outreach effort aimed at forming relationships with unsheltered individuals, identifying their barriers to entering permanent supportive housing and assisting them in overcoming these barriers. Having identified this population’s need for medical services, in 2007 faculty in Jefferson Family Medicine Associates (JFMA) reached out to Project HOME and extended an ongoing community-academic partnership. Since then Family Medicine residents and students have been traveling with the outreach team, meeting people identified by Project HOME as having an acute medical need. The medical street outreach program sees over 150 patient visits annually and is organized and operated entirely by residents in the Department of Family and Community Medicine

Moving From Street to Home: Health Status of Entrants to a Housing First Program

Housing First (HF) is an evidence-based practice that ends chronic homelessness for individuals with serious mental illness by providing immediate access to permanent independent housing and team-based community supports. Little is known about the health status of homeless individuals entering HF programs. Through a cross-sectional analysis, this paper reports on the chronic physical disease burden of people entering a newly established HF program and examines whether these individuals recognize and request support for ongoing health-related issues. The authors’ evaluation confirmed significantly higher rates of chronic disease (60%) and fair/poor self-reported health status (47%) than the general urban population of Philadelphia. The majority of clients reported they wanted to address both medical (67%) and mental health (68%) problems, but a much lower percentage reported wanting to reduce substance use (23%) or take psychiatric medications (25%). The authors conclude that formerly homeless entrants to HF programs have a high burden of chronic disease with complex health-related needs. Additionally, these individuals look to the program for health-related assistance. As the HF model is disseminated throughout the United States to end chronic homelessness, these findings support the development of flexible, integrated, person-centered health services within the HF service delivery system as a potentially effective method to address complex health needs